Mistake that cannot be done by nurse

Pediatric Critical Care Columnist · Apr 4, 2012

It's vitally important NOT to infuse air into central lines; most particularly so in patients with cyanotic cardiac defects. The reason it's so important in these patients especially is that their circulation mixes somewhere and air bubbles in a central vein could well end up going directly to their brain, causing a stroke. The person who was supervising you should have stopped you from infusing the blood back into the patient once the bubble had been seen. Having said that, it happens all the time that tiny bubbles are accidentally infused into central lines. Most of the time there is no adverse outcome from a 1-2 mm diameter bubble. The lesson from this is to be scrupulous in handling central lines of any kind and on any patient... scrupulous sterile technique, scrupulous avoidance of infusing air, scrupulous technique when flushing.

deepurple · Apr 4, 2012

when i withdraw the hepsaline into syringe 1cc ..i'd already draw out the air so at first, my syringe 1cc was free of bubble...then when i flush the hepsaline about the 0.5cc hepsaline into neck line, i'd withdraw a liitle bit of blood to see whether the neck line is functioning or not. this technique had been taught by another senior staff nurse. But what happen is my mistake that i didn't see the bubble properly. My senior nurse at that time who supervised me saw that bubble didn't stop me when i want injected back to finish my flushing with hepsaline. I am query about the bubble that came at that time i withdraw the blood..is it harmful to the patient, i didn't know how much the bubble is but it came from when i withdraw from the line. so now what must i observe the patient.? i am so so so worry...

Pediatric Critical Care Columnist · Apr 4, 2012

There are a few details missing from your account of what happened. When you drew up your heparinized saline, did you change the needle/blunt tipped cannula afterward? If you did change it, did you then purge the air from the dead space in the new one? When you flushed the line, were you using a port on the IV tubing or were you using a capped port on the line itself, or were you using an open stop cock?

It was quite clear in your initial post that you were supervised by someone who didn't stop you from infusing air into your patient. What isn't clear is why you didn't ask the person who was supervising you what the damage would be from injecting a small air bubble into your patient. That's what I'd expect the average, prudent nurse to do.

If the bubble had caused harm to your patient you'd see evidence of impaired or obstructed blood flow and they would be dependent on the path the bubble took. I think you know what those would be. If the child has an acyanotic defect or has been completely repaired, the venous blood goes to the right atrium, right ventricle then to the pulmonary arteries. So the bubble would have ended up in a lung where it would likely diffuse out and there would be no problems. If there is mixed circulation the bubble could have gone to the brain. What are the signs of stroke??

deepurple · Apr 4, 2012

When i flushed the line, i was using an open stop cock. About what you have said that if there is mixed circulation the bubble could have gone to the brain,it makes me more and more worry.

morte, LPN, LVN · Apr 4, 2012

IF there was a bubble in the syringe, where did the air come from? Or was it a space made by the vacuum of pulling back on the plunger?

Pediatric Critical Care Columnist · Apr 4, 2012

If you were using an open stop cock and didn't fill the port with fluid before attaching your syringe, that's where the air came from. When you remove a dead ender (cap) from the port there's a small amount of dead space there that isn't filled with either syringe or fluid at the time of connection. It amounts to microlitres of air, but air none the less. My personal practice when using open stop cocks on any IV, central or peripheral, is to spill flush solution into the port as I'm attaching the syringe. It's hard for me to tell you exactly how I do it without being able to show you, but I'll try. I always have more fluid in the syringe than I'm going to need, first of all. I clean off the dead ender and port with chlorhexidine/alcohol swabs before I remove the dead ender. Then I clean the port itself. Holding the syringe with my flush solution in it perpendicular (90 degree angle) to the open port (which is held open side up and pointed at the ceiling), I slowly dribble fluid into the open port until it fills it completely and spills a few drops onto the gauze i've put underneath. Once the port is completely filled, I attach the syringe onto the port. A few more drops of fluid will be displaced onto the gauze, but there will be no air in the port. Then I flush, aspirate a bit of blood back and continue. Does this make sense?

Deepurple, what was the child's underlying cardiac defect and what repair had been done? Knowing that will tell me more about the likelihood of the air going to the brain.

deepurple · Apr 5, 2012

Thank you for your reply...and thank you for sharing your personal practice, it would be nice if i can see how you do it rather than you explain to me...well it's okay...i really appreciate it. That child had undergone tretalogy of fallot correction and ventricle septal defect closure. today is post-op day 9.

Pediatric Critical Care Columnist · Apr 5, 2012

So this patient has normal (94-100%) oxygen saturations? If that's the case, then the corrective surgery has eliminated the right-to-left shunting that would cause air embolization to the brain. The baby will likely be just fine.

I'll see if I can get someone to photograph spill-priming so you can see how it's done. I don't go back to work for a couple of days and then I won't have time to post photos for at least 3 days. Check back mid-next week.

morte, LPN, LVN · Apr 5, 2012

If it is a three way, could you close to patient, open the side port and flush the other and close off to side port, in the act of flushing, and obtain the same?

So this patient has normal (94-100%) oxygen saturations? If that's the case, then the corrective surgery has eliminated the right-to-left shunting that would cause air embolization to the brain. The baby will likely be just fine.
I'll see if I can get someone to photograph spill-priming so you can see how it's done. I don't go back to work for a couple of days and then I won't have time to post photos for at least 3 days. Check back mid-next week.

Pediatric Critical Care Columnist · Apr 5, 2012

You could do that morte, and I have. But if I'm planning to flush the line already and have the flush syringe in hand it's quicker and easier to just spill-prime.

deepurple · Apr 7, 2012

One of my senior staff nurse who taught me how to avoid injecting the air into the line. I think like what you have said, lock the syringe into the stopcock and point upwards 90 degree and tap the syringe so that the air is going upward and then the bubble will not go into the line. Isn't it?